Age_Wilkison` ���a
`= AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP veaR
'Y3 � REQUESTING DEDUCTION FROM ASSESSED VALUATION
S ��� Sute Fonn 43708 (R6/ a-Oa)
Prescribed by Ne Depariment ot Lowl Govemment Finance
�•• File Mark
Information contained in this documenl is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.135-9.
INSTRUCTlONS: � fj'�I�A��
To be filed in person or by mail with the CountyAuditor o/ the county where � �y� p g the 12 months be%re May
the p�operty is located. 11 0( the year the deducfion is to 6e eHective.
�R1o8il�a�jQ� assessed under I.C.6-1-1-7;
See reverse side (o� additional instruction and oualifications. 6etween January 15 and March 31 of the yea�
�—,_,�e dedlicf' n is to be eHective.
O��a� ,l��
Nameofa plica (ownerorcontractbuyeQ �� �G�BSONCOUNTYAUDITOR
Is applicant e e legal or equitable owner? If No, what is hisfher exact share or interest? If owned with someone other than spouse,
' indicate with whom
p Yes ❑ No
If name on record is diRerent ihan thal of applicant, indicate below
Name ot contract seller (applicant musf have been buying on confract at least one (1) year)
Address of wniract seller Is the property in question:
❑ Real property ❑ Mobile home (I.Q 674-n
district Key number / legal description � Rewrd number Page number
I � ("d��"�O
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may nof
hisRier residence? exceed 5144,000)
es � No
Was the applicant 65 years o( age or more on December 37 the year poes the wmbined annual adjusted grou income o( the appliwnt and any
prior to ihe curtent year? individuals sharing ovmership exceed $25,0007
es ❑ No ❑ Yes ❑ No
AppliwnYS
$
Have you filed for any other deductions? If Yes, what deducUons? .
❑ Yes ❑ No
Have you filed tor deductions in any other wunty? If Yes, what wunty?
❑ Yes ❑ No
INVe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
S' nature of apJplicant Signature ot authorized representative (by executed Power o)Attomey)
/ , �
.ress of applicant Address of authorized representative
�iC,F(7